HESI Fundamentals (NCLEX ) Final Exam - Questions and Answers An elderly patient has been living in a nursing home for several years. The nursing staff
... [Show More] has begun to notice a change in her behavior. All of the following are symptoms of depression except: a. Changes in sleep patterns b. Changes in eating patterns with weight loss c. Excessive fatigue and increased concern with bodily functions d. Hyperorality The census on the unit is 90 percent and there are no private rooms available. An elderly client with influenza is admitted. Which of the following rooms would it be appropriate to assign this client? a. A double room with a client admitted for impetigo. b. A double room with another client with the same diagnosis. c. A four-bed room with three clients who have had orthopedic surgery. d. A double room with an elderly client with a diagnosis of chickenpox. If a private room is not available, the client should be placed with another client with the same diagnosis where droplet precautions would already be in place. The staff and visitors should be told to stay at least 3 feet away without a mask because large-particle droplets travel only about 3 feet before falling from the air. You are assigned to teach a nursing student how to suction an adult patient with a tracheostomy. Which of the following actions by the nursing student would be INCORRECT? a. Pre-oxygenation of the patient with a Resusibag at 100% 02 several times before suctioning b. Maintains wall suction pressure at 110-150mmHG c. Does not suction for greater than 10-15 seconds at a time d. Applies gentle intermittent pressure and rotates catheter during insertion phase of suctioning In suctioning a patient with a Tracheostomy, the nurse should employ all of the above choices, except choice (4). However, when the catheter is inserted it should be done gently, and to a depth of 10-12.5cms (4-5"s) or until the patient begins to cough. Suction should never be applied when inserting the catheter, not should it be rotated during this period. Suction should be applied by occluding the Y-port with the thumb of the unsterile gloved hand, while the catheter is rotated gently during withdrawal. The patient should never be suctioned for more than 10 seconds at one time to avoid the development of hypoxia. When a client has suffered severe burns all over his body, the most effective method of monitoring the cardiovascular system is a. Cuff blood pressure. b. Arterial pressure. c. Pulmonary artery pressure. d. Central venous pressure. When is the first dose of Hep B given? In the hospital at birth An adult has just died. How should the nurse prepare the body for transfer to the mortuary? a. Leave the body as is, no prep needed b. Bathe the body and put ID tags on it c. Remove dentures before bathing body d. Position the body with its head down and arms folded on its chest. A patient has decreased cardiac output following a surgery. What will the nurse likely see in this patient? a. Decreased urine output b. Increased urine output c. Flushing of the skin d. Hyperventilation The nurse counts an adult's apical heart [Show Less]